Provider Demographics
NPI:1447681499
Name:ALLEN, ALEXANDRA (MA, CCC-SLP/L)
Entity type:Individual
Prefix:MRS
First Name:ALEXANDRA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2723 N 39TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62201-2155
Mailing Address - Country:US
Mailing Address - Phone:618-803-1910
Mailing Address - Fax:
Practice Address - Street 1:105 W A ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1326
Practice Address - Country:US
Practice Address - Phone:618-233-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011641235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist